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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002949
Report Date: 07/10/2024
Date Signed: 07/10/2024 02:53:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20240709103107
FACILITY NAME:DELTA AT HOLLY OAKSFACILITY NUMBER:
515002949
ADMINISTRATOR:LEONARD WILLIS IIFACILITY TYPE:
735
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 618-5615
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:70CENSUS: 41DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leonard WillisTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff not following mandated reporting requirements
INVESTIGATION FINDINGS:
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LPA Hiratsuka conductedt this unannounced complaint visit.

LPA interviewed Administrator Leonard Willis. This complaint was made because a resident informed several staff of being inappropriate touched by another resident. Administrator didn't complete an SOC 341, Suspected Dependant Adult/Elder Abuse form. Administrator stated he did an investigation and didn't write down anything. LPA did speak to the resident in question but the incident itself cannot be proved or disproved.

As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.
Exit interview conducted. A copy of the report has been issued. LPA also left a copy of the Title 22 Regulation. Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20240709103107
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA AT HOLLY OAKS
FACILITY NUMBER: 515002949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/10/2024
Section Cited
CCR
80061(d)
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Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and
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By 08/10/2024, the licensee shall ensure staff review reporting requirements for suspected abuse and also come up with a written plan for the facility staff to follow when someone reports they were abused and submit a copy of that plan to Community Care Licensing.
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Institutions Code Section 15630(b)(1). Based on interview it was determined licensee failed to ensure staff reported inappropriate touching to the agencies required by the Welfare and Institution Code. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
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